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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801008
Report Date: 10/11/2022
Date Signed: 10/11/2022 04:25:37 PM

Document Has Been Signed on 10/11/2022 04:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALAMEDA HOUSEFACILITY NUMBER:
425801008
ADMINISTRATOR:NICHOLAS PAPAGEORGEFACILITY TYPE:
735
ADDRESS:7167 ALAMEDA AVENUETELEPHONE:
(805) 685-1111
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 6CENSUS: 5DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Jennifer Goddard, Co-AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection visit to the above-named facility. LPA arrived at 2:20 pm and was greeted by Staff 1 (S1). LPA explained the purpose of the visit. Jennifer Goddard, Administrator arrived at approximately 2:47 pm.

Entrance interview conducted.
At the time of arrival, there were five residents in care and one staff on duty. The facility is a single-story home to residents with a mental illness diagnosis. The facility contracts with Santa Barbara County Behavioral Wellness.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. Fire inspection was last conducted on 9/13/2022. The carbon monoxide alarm and six smoke alarms are in good working order.
The kitchen area was sufficiently stocked with at least two days of perishables and seven days of non-perishables.
The facility has an entry station at the front door entering the facility. Upon entry, staff, visitors, and clients who are returning from an outing are required to sign-in and have a temperature screening. All documentation is kept in a binder in the locked staff office. Documentation is filed on a regular basis.
PPE gear, hand sanitizer, disinfecting wipes, disinfecting spray, gloves, masks, and thermometers, and backup PPE are kept in the staff office and in a garage located at the back of the facility grounds. A backup supply is also kept at the Mental Wellness Center which is off-site from the facility.
Please continue to 809-C, Pg 2.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALAMEDA HOUSE
FACILITY NUMBER: 425801008
VISIT DATE: 10/11/2022
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 The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The facility was seen to be in good repair inside and outside.
LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean.
Medications, First aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet in the staff office.
There are 3 shared bedrooms with sufficient lighting, nightstands and beds. Bedroom 1 has a shared bathroom. Bedrooms 2 and 3 share a bathroom off the main hallway of the facility.
If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other negative individuals until cleared by Health Department. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of COVID-19. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals.
PPE supplies will be located immediately outside those rooms when required. Facility has a 30-day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room.
The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results.
Facility has conducted training an infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Staff who have a respiratory illness are requested to stay home and not report to work.
Activities have been modified to individuals or small groups with social distancing. Residents' medication is delivered in 30-day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items.
Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in the locked staff office. Facility observes guidance changes and the most up-to-date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Administrator Certificate is valid.
All staff have passed a criminal background clearance and are properly associated to the facility.

Exit interview conducted. No citations issued. A copy of this report has been issued via email.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
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